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November 2005 Part B Medicare Bulletin

Posted November 4, 2005

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2nd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule 2005 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs - Revised

2nd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule 2005 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs - Revised

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3rd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule 2005 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs - Revised

3rd Quarter Update Part B Not Otherwise Classified Drug Fee Schedule 2005 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs - Revised

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4th Quarter Update Part B Not Otherwise Classified Drug Fee Schedule 2005 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs

4th Quarter Update Part B Not Otherwise Classified Drug Fee Schedule 2005 Payment Allowance Limits for Medicare Part B Not Otherwise Classified (NOC) Drugs

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Annual ICD-9 Update

The Annual ICD-9 Update for 2005 effective October 1, has been completed for Tennessee, Idaho, and North Carolina. All policies that were affected have been updated to reflect the new ICD-9 codes. Please refer to the CIGNA Government Services Part B Web site for ICD-9 Updates, Revised LCDs and New Draft LCDs .

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Cessation of Additional $50 Payment for New Technology Intraocular Lenses (NTIOLs)

Provider Types Affected
Ambulatory Surgical Centers (ASC) that bill Medicare carriers for Intraocular Lenses (IOL)

Provider Action Needed
Effective for dates of service on or after May 19, 2005, HCPCS codes Q1001 and Q1002 expire for services performed in ASC settings. Previously, Medicare paid an additional $50 payment to ASCs for NTIOLs billed with Q1001 and Q1002, but the five-year payment adjustment period for these codes expires on May 19, 2005.

Background
In 1999, Section 1833 (i)(2)(A)(iii) of the Social Security Act (the Act) required that the Centers for Medicare & Medicaid Services (CMS) establish a process that designated particular intraocular lenses (IOLs) as “new technology” and these IOLs became eligible for an additional $50 adjustment for NTIOLs (codes Q1001 and Q1002). This payment was effective from May 18, 2000, to May 18, 2005, and could be billed only by the ASC.

For dates of service on or after May 19, 2005, Medicare carriers will no longer pay the $50 additional payment to ASCs on claims for NTIOLs billed with HCPCS codes:

Implementation
The implementation date of CR3901 is October 3, 2005.

Additional Information
The official instruction issued to your carrier regarding this change may be found by going to http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site.

From that Web page, look for CR3901 in the CR NUM column on the right, and click on the file for that CR.

CR3901 also includes the portions of the Medicare Claims Processing Manual that were revised to reflect this change.

For additional information relating to this issue, please refer to your carrier. To find their toll free phone number, go to http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

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Contingency and MSP Claims

The Centers for Medicare & Medicaid Services (CMS) has received a number of inquiries about the impact of termination of the contingency plan for incoming claims on October 1, 2005, on submission of Medicare Secondary Payer (MSP) claims. The following information is being furnished to clarify the Medicare requirements for submission of compliant MSP claims as required by the Health Insurance Portability and Accountability Act (HIPAA).

On August 4, 2005, CMS announced that the HIPAA contingency period for claims sent to Medicare would end on October 1, 2005. This termination does not apply to claims that Medicare sends outbound to other payers that have signed a coordination of benefits (COB) trading partner agreement for the transfer of claims by Medicare. It does apply to claims sent to Medicare for secondary payment following processing by a primary payer, however. Therefore, effective October 1, 2005, electronic MSP claims must comply with all X12 837 version 4010A1 implementation guide requirements, and include standard claim adjustment reason (CAS) codes to describe adjustments that a primary payer made during adjudication, or they will be rejected.

CMS is aware of provider concerns that primary payers frequently send paper explanations of benefits or 835 transactions that contain local messages or codes rather than standard CAS codes. HIPAA does not require that standard CAS codes be reported in paper explanations of benefits, and payers that still have an X12 835 HIPAA contingency plan in effect may not yet be able to report standard CAS codes. HIPAA does require health care benefit payers to send providers X12 835 version 4010A1 transactions if requested by providers, and those 835 transactions must contain standard CAS codes by the end of each payer’s 835 contingency period.

CMS is working with the HIPAA standards committee that maintains the CAS codes to develop a simplified means to translate non-standard messages and codes into standard CAS codes. We expect this process to be approved and implemented quickly. However, until an alternate solution is approved for use, electronic MSP claims sent to Medicare are required to contain standard CAS codes, along with other loops, segments, and data elements that apply. It is the provider’s responsibility to convert local adjustment reason codes or messages into the appropriate standard CAS codes prior to transmission of an 837 version 4010A1 claim to Medicare for secondary payment.

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Enforcement of Hospital Inpatient Bundling: Carrier Denial of Ambulance Claims During an Inpatient Stay

NOTE: This article was revised on September 6, 2005, to reflect changes made when CR3933 was revised. The only changes made to the article reflect the new CR release date and transmittal number (see above). All other information remains the same.

Provider Types Affected
Independent ambulance services suppliers billing Medicare carriers

Provider Action Needed

STOP – Impact to You
Independent ambulance services suppliers cannot bill Medicare carriers for ambulance services that they provide to hospital inpatients (on or after 12/31/04), unless the services are provided either:

If services other than these two scenarios are billed separately as Part B, the bills will be rejected. (There are exceptions for patients of long-term care hospitals, inpatient psychiatric facilities, or inpatient rehabilitation facilities as discussed later in this article.)

CAUTION – What You Need to Know
If an ambulance supplier bills Medicare and is paid prior to Medicare’s receipt of the hospital inpatient claim, Medicare will recover the improper payment from the ambulance supplier.

GO – What You Need to Do
Make sure that your billing staffs are aware of these ambulance service billing requirements.

Background
The Centers for Medicare & Medicaid Services (CMS) is strengthening its claims processing edits to detect incorrect payments to detect and prevent (or correct) improper payments to ambulance suppliers for transporting hospital inpatients. In CR 3933 (on which this article is based), CMS wants to make you aware of the rules that govern payment for the ambulance services that such suppliers provide to hospital inpatients.

Sections 1882(a)(14), 1886(d) and (g) of the Social Security Act, and Code of Federal Regulations (CFR) 411.15(m) disallow payment for ambulance services furnished to hospital inpatients on dates that fall between the patients’ admission and discharge dates, unless the hospital bills for services directly or makes special arrangements for the services with the independent ambulance supplier.

As a result, the independent supplier of ambulance services must look to the hospital for payment for these services, rather than to the Medicare beneficiary or carrier. More specifically, with the exception of services on the admission and discharge dates, all ambulance transportation provided to hospital inpatients must be bundled into the hospital bill. Medicare carriers will reject any bill for ambulance services that are provided to a hospital inpatient on a date that falls between their admission and discharge dates.

In summary, here is how this process works. Effective for dates of service on or after December 31, 2004, Medicare’s systems search the paid claim histories of independent suppliers of ambulance services and compares the line item service dates (line items with specialty codes of “59”) on the ambulance claims to the admission and discharge dates on hospital inpatient stays. Medicare then rejects the line items when an ambulance line item service date falls between the admission and discharge dates on a hospital inpatient bill.

And, if Medicare receives the ambulance claim prior to receiving the hospital inpatient bill, it performs the same search and if the ambulance claim falls within the admission and discharge dates, the ambulance claim is adjusted and the incorrect payment for the ambulance service will be recovered from the ambulance supplier.

Note: There is a special group of ambulance transportation payment situations that are permitted for inpatients of certain facilities. Specifically, these payments are permitted when the beneficiary is an inpatient of a long term care facility (LTCH), inpatient psychiatric facility (IPF), or inpatient rehabilitation facility (IRF), and is transported by ambulance to an acute care hospital to receive specialized services and the service date falls within the occurrence span code 74 (non-covered level of care) from and through dates, plus one day, on a LTCH, IPF, or IRF bill.

Finally, when Medicare rejects/adjusts an ambulance claim, the carrier will indicate, by using Remittance Advice Remark Code M2: “Not paid separately when the patient is an inpatient;” that:

  1. The ambulance transportation occurred during a hospital inpatient stay (on a date that falls within the admission and discharge dates of a covered hospital inpatient stay), and is not separately
    payable, or
  2. The service date falls outside the occurrence span code 74 (non-covered level of care) from and through dates plus one day on a LTCH, IPF or IRF, and is not separately payable.

In addition, the carrier will also indicate the adjustment using Remittance Advice (RA) Adjustment Reason Code 97 “Payment is included in the allowance for another service/procedure.”

Additional Information
You can find more information about the payment of ambulance claims during an inpatient stay by going to http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site. From that Web page, look for CR3933 in the CR NUM column on the right, and click on the file for that CR.

You might also want to look at the Medicare Claims Processing Manual, Chapter 3 (Inpatient Part A Hospital) Section 10.5 (Hospital Inpatient Bundling). You can find this manual chapter as an attachment to CR3933.

Finally, if you have any questions, please contact your carrier at their toll-free number, which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

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Evaluation and Management Visits Online Training Course

Web-Based Training on “Evaluation and Management Basics and Common Errors” is now available on the CIGNA Government Services Web site. This NetCourse was developed by CIGNA Government Services Part B Medical Review staff based on the guidelines established by the Centers for Medicare and Medicaid Services. This NetCourse is the first of three netcourses on evaluation and management documentation guidelines and scoring. The second and third courses will be forthcoming. Providers should watch the CGS Web site or enroll in ListServe to receive announcement on release of these other courses. All of the courses are designed to educate and faciliate providers’ selection of the appropriate (i.e. medically necessary) level of E&M service to bill to Medicare. The courses reflect the guidelines used by the Medical Review department as well as the Comprehensive Error Rate Testing program on the review of E&M services. Providers are encouraged to have whoever determines in their practice the level of E&M encounters billed to Medicare to take this course. This course can be accessed via the following Web address: http://www.cignamedicare.com/Webtraining/Logon.asp

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Financial Liability for Services Subject to Home Health Consolidated Billing Provider Types Affected

Home Health Agencies (HHAs) and providers and suppliers of services to Medicare patients in a home health episode of care

Provider Action Needed
This instruction is intended mostly as an informational refresher. However, the article and CR3948 clarify guidance regarding Home Health Services (HHS) consolidated billing, particularly the guidance that addresses potential provider and beneficiary liability for payment. Providers/Suppliers treating Medicare patients in an episode of home health care are encouraged to review the entire CR3948. Instructions for accessing CR3948 are provided at the end of this article.

The Centers for Medicare & Medicaid Services (CMS) is providing this information because questions about payment liability have persisted since the Home Health Prospective Payment System (HH PPS) was implemented in October 2000. CMS believes that providing clear answers in the Medicare Claims Processing Manual will help you better understand HH PPS.

Background
Section 1842 (b)(6)(F) of the Social Security Act requires consolidated billing for all home health services that are included under a physician-authorized home health care plan. Earlier guidance and information about HH PPS consolidated billing was primarily published in articles attached to Program Memoranda.

CR3948 (from which this article is taken) improves the organization of and clarifies instructions about HHPPS. In particular, it identifies circumstances in which providers or beneficiaries may be liable for payment for services subject to HH PPS consolidated billing.

A Short Summary of the Guidance
Under HHS consolidated billing, only the primary HHA can bill for services included in a beneficiary’s home health benefit during the beneficiary’s HHA episode of care. With the exception of Durable Medical Equipment (DME) and physician-provided therapy services (discussed below), Medicare will not separately pay other providers or suppliers for any home health services that they render. Therefore, providers and suppliers of home health services should be aware that, under certain circumstances, they, or the beneficiary, could potentially bear the cost of these services.

The Guidance in More Detail
HH PPS consolidated billing provides that the Medicare payment for all of a beneficiary’s home health items and services is to be made to a single (known as “primary”) HHA that oversees that beneficiary’s physician-authorized home health plan. This primary HHA is the only agency that may bill Medicare for home care for a given homebound beneficiary at a specific time. Further, the payment Medicare makes is to the primary HHA, regardless of who actually furnishes the service (including services furnished by others under arrangement to the primary HHA, by any other contracting or consulting arrangements existing with the primary HHA, or by any other mechanism).

However, while the primary HHA is responsible for providing all of a patient’s home health services, they would not be responsible for payment to another provider if they were unaware of the physician’s orders for that service. Therefore, if an independent provider/supplier were to provide the beneficiary a home health service that was already consolidated into the HHA’s payment, their claim would be denied by Medicare and they would not receive payment.

Types of Services Subject to Home Health Billing
The following types of services are subject to this home health consolidated billing provision, and are included in the primary HHA’s payment:

Two types of services, however, are an exception to this guidance, and are therefore not subject to the home health consolidated billing methodology. These services are:

Billing of Durable Medical Equipment
DME warrants some further discussion. DME may be billed by a supplier to a Durable Medical Equipment Regional Carrier (DMERC) or billed by an HHA (including HHAs other than the primary HHA) to a Regional Home Health Intermediary (RHHI). To prevent duplicate RHHI and DMERC billing (the same dates of service for the same beneficiary), Medicare system edits ensure that all DME items billed by HHAs have a line-item date of service and HCPCS code, even though, by law, HH consolidated billing does not apply to DME. If the RHHI and the DMERC receive duplicate bills (for either purchase or rental), the first claim received will be processed and paid, and the subsequent duplicate claims will be denied.

How Do You Protect Yourself and the Beneficiaries?

In general, all providers and suppliers serving a home health patient should attempt to protect the beneficiary from unexpected liability by notifying them of the possibility that they can be responsible for payment.

Primary HHAs
Let’s first discuss your responsibilities if you are the primary HHA. When a homebound beneficiary seeks care from you, you need to determine if they are already being served by a primary HHA. You can ask the beneficiary or his/her representative, if they are already being served by an HHA. Or, you can send an inquiry to your RHHI.

If the response indicates that the beneficiary is not already under the care of another HHA, you may admit them and you will become primary. The HHA that submits a successfully processed request for anticipated payment (RAP) or No-RAP Low Utilization Payment Adjustment (LUPA) will be recorded as the primary HHA for a given episode in the Common Working File (CWF).

You may also admit them, even if an episode is already open at another HHA, if the patient has chosen to transfer. If a beneficiary transfers during a 60-day episode, then the transfer HHA that establishes the new plan of care assumes responsibility for that patient’s consolidating billing.

At the time of their initial home health care admission, you, as the primary HHA, must advise the patient that you will be providing all of their home health services, including therapies and supplies.

You must also explain the disciplines (e.g., skilled nursing, physical therapy, home health aide, etc.) that will be furnishing their care, and the proposed visit frequency.

In addition, you must advise the patient, in advance (both orally and in writing), about possible payment sources, including what Medicare is expected to cover, as well as other payment sources, including payment from the patient. This discussion should help alert the beneficiary to the possibility of payment liability if they were to obtain services from anyone other than their primary HHA.

Independent Providers/Suppliers
Since Medicare payment for services that fall under home health consolidated billing is made to the primary HHA, independent providers or suppliers of these services need to understand that Medicare will not pay you separately. Therefore, before you provide a homebound beneficiary any services, you need to first determine if they are being served by a primary HHA.

To get this information you can, first, ask the beneficiary (or their authorized representative) if they are currently receiving home health services under a home health plan of care. In fact, beneficiaries and their representatives should have the most complete information as to whether or not they are receiving home health care. But, beneficiary-derived HH information, in and of itself, does not shift liability to either the beneficiary or to Medicare. Additionally, you can ask your intermediary or carrier.

Institutional providers who bill Fiscal Intermediaries (FIs) can access this information electronically through the home health Common Working File (CWF) inquiry process (See Chapter 10, Section 30.1, Health Insurance Eligibility Query to Determine Episode Status attached to CR3948.) Independent therapists who bill carriers or suppliers who bill DMERCs can call the provider toll free line to request home health eligibility information available on the CWF. (Those toll free numbers are available at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.) But remember that the carrier’s or DMERC’s information is based only on claims Medicare has received from HHAs by the day of the contact.

If you are concerned about the reliability of any of this information, you should advise the HH beneficiary that if they decide to accept your services rather than those provided by the primary HHA, they can be liable for the payment.

Finally, if you learn of a home health episode and contact the primary HHA, you might inquire about the possibility of making a payment arrangement with them for the service. Such contacts may foster relationships between therapy providers, suppliers and HHAs that are beneficial both to the providers involved and to Medicare beneficiaries.

Hospitals
Hospitals are responsible for making Medicare beneficiaries and caregivers aware of Medicare home health coverage policies in order to:

Under the Medicare Conditions of Participation (COP) for Hospitals: Discharge planning, (42 CFR, §482.43 (b) (3) and (6)), your discharge planning process must include an evaluation of the likelihood that a patient will require post-hospital services and an evaluation of their availability. Hospitals need to counsel those beneficiaries who are to receive HH services after discharge that their primary HHA will provide all of their home health services. You should also provide them with a list of HHAs from which to choose, and notify the agency that you are referring the patient to and provide the agency with any counseling notes. This should serve as a reminder to the HHA to notify the beneficiary that they will be providing all of their HH services.

Other Important Information

Institutionalizing an HH patient
Under HH PPS, claims for inpatient hospital and Skilled Nursing Facility (SNF) services have priority over claims for home health services. Because institutionalized beneficiaries cannot receive home care, if Medicare detects dates of service on an HH PPS claim that fall within the dates of an inpatient or SNF claim (not including the dates of admission and discharge), the RHHI will reject the HH claim.

This will be the outcome even if the HH PPS claim were received first and the SNF or inpatient hospital claims came in later.

Edits and Denials
Claims subject to consolidated billing may be identified either pre-payment or post payment. HH consolidated billing editing is applied when Medicare has received and processed the episode claim. Any line item services within the episode start, and end, or last billable service dates, will be edited.

Medicare sends information to the FIs and carriers that enable them to reject or deny line items on claims subject to consolidated billing. This rejection or denial may take place either prior to, or after, payment. If it occurs after payment, Medicare notifies the FI or carrier to make a post-payment rejection or denial. FI post-payment recoveries will be made automatically in the claims process, and carriers follow their routine overpayment identification and recovery procedures.

Important editing issues include the following:

The FI or carrier will process the claim for payment, but also alerts the provider on the remittance advice with remark code N88: “This payment is being made conditionally. An HHA episode of care notice has been filed for this patient...This payment will need to be recouped from you if we establish that the patient is concurrently receiving treatment under an HHA episode of care.”

Osteoporosis drugs are subject to home health consolidated billing, even though they continue to be paid on a cost basis. Only a primary HHA can bill for their use by Medicare patients in an episode of care. For more detailed information, refer to Section 90.1 of Chapter 10 of the Medicare Claims Processing Manual, which is available at http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp on the CMS Web site.

Additional Information
This article summarizes the information made available in CR3948. Providers treating Medicare patients in a home health episode of care are encouraged to be familiar with all the details of CR3948.

You can find CR3948 at http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site.

From that Web page, look for CR3948 in the CR NUM column on the right, and click on the file for that CR.

CR3948 includes revised portions of the Medicare Claims Processing Manual related to the HHPPS.Finally, if you have any questions, please contact your carrier/DMERC/intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

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Frequency Instructions for Smoking and Tobacco-Use Cessation Counseling Services

I. SUMMARY OF CHANGES: The Centers for Medicare & Medicaid Services issued new instructions under CR 3834 dated May 20, 2005, to cover two new levels of counseling for smoking cessation counseling services (intermediate and intensive) effective March 22, 2005. The new coverage is published in section 210.4 of Pub. 100-03, National Coverage Determinations Manual. This CR provides instructions for the implementation of frequency editing for smoking and tobacco-use cessation counseling services. Such services are limited to 8 counseling sessions in a 12-month period.

NEW/REVISED MATERIAL :
EFFECTIVE DATE : October 1, 2005
IMPLEMENTATION DATE : October 3, 2005

Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.

II. CHANGES IN MANUAL INSTRUCTIONS:
R = REVISED, N = NEW, D = DELETED

R/N/D CHAPTER/SECTION/SUBSECTION/TITLE
R 32/12.4/Remittance Advice (RA) Notices
R 32/12.5/Medicare Summary Notices (MSNs)

III. FUNDING:
No additional funding will be provided by CMS; contractor activities are to be carried out within their FY 2005 operating budgets.

IV. ATTACHMENTS:
Business Requirements
Manual Instruction

*Unless otherwise specified, the effective date is the date of service.

I. GENERAL INFORMATION: The Centers for Medicare & Medicaid Services (CMS) issued CR 3834 dated May 20, 2005, which included initial claims processing instructions, business requirements, and a national coverage determination (NCD) for smoking and tobacco-use cessation counseling. CR 3834 did not include related frequency editing. This CR provides for frequency editing for such services.

A. Background: Tobacco use continues to be the leading cause of preventable death in the United States. In 1964, the Surgeon General of the U.S. Public Health Service (PHS) issued the report of his Advisory Committee on Smoking and Health, officially recognizing that cigarette smoking is a cause of cancer and other serious diseases. Though smoking rates have significantly declined, 9.3% of the population age 65 and older smokes cigarettes. Approximately 440,000 people die annually from smoking related disease, with 68% (300,000) age 65 or older. Many more people of all ages suffer from serious illness caused from smoking, leading to disability and decreased quality of life. Reduction in smoking prevalence is a national objective in Healthy People 2010.

B. Policy: Effective March 22, 2005, CMS determined that the evidence is adequate to conclude that smoking and tobacco use cessation counseling, based on current PHS guidelines, is reasonable and necessary for certain individuals who use tobacco and have a disease or an adverse health effect that has been found by the U.S. Surgeon General to be linked to tobacco use, or who are taking a therapeutic agent whose metabolism or dosing is affected by tobacco use as based on Food and Drug Administration-approved information. These individuals will be
covered under Medicare Part B when certain conditions of coverage are met, subject to certain frequency and other limitations.

II. BUSINESS REQUIREMENTS
“Shall” denotes a mandatory requirement
“Should” denotes an optional requirement

Requirement Number Requirements Responsibility ("X" indicates the columns that apply)
    F I R H
H
I		 C a
r
r
i
e
r
s		 D M E
R
C		 Shared System Other
F I
S
S		 M C
S		 V M
S		 C
W F
3929.1

Beginning with dates of service on or after October 1, 2005, the Common Working File (CWF) shall edit for the frequency of service limitations for Smoking and Tobacco-Use Cessation Counseling. Medicare systems shall allow codes G0375 and G0376 for Smoking and Tobacco-Use Cessation Counseling services for a combined total of up to 8 sessions per 12-month period.

Note: Start the count for the second or subsequent 12-month period for Smoking and Tobacco-Use Cessation Counseling services beginning with the month after the month in which the first Medicare covered cessation session was performed and count until 11 full months have elapsed. For example, if the first of 8 covered sessions is performed in April 2005, a second series of 8 sessions may begin in April 2006.

              X  
3929.2 Upon reject from CWF, contractors shall deny claims for G0375 and G0376 when the dates of service exceed a combined total of 8 sessions in a 12-month period.
X X X   X     X  
3929.3 Upon reject from CWF, contractors shall deny claims for G0375 and G0376 when the dates of service exceed a combined total of 8 sessions in a 12 month period. X X X            
3929.4 Contractors shall use an appropriate claims adjustment reason code such as 119, "Benefit maximum for this timeperiod or occurrence has been reached" when the claim is being denied for frequency purposes. X X X            
3929.5 Contractors shal instruct providers to issue an Advanced Beneficiary Notice (ABN) to beneficiaries advising them of poetntial financial liability if all specified conditions for coverage of Smoking and tobacco-Use Cessation Counseling are not met. X X X            

III. PROVIDER EDUCATION:

Requirement Number Requirements Responsibility ("X" indicates the columns that apply)
    F I R H
H
I		 C a
r
r
i
e
r
s		 D M E
R
C		 Shared System Other
F I
S
S		 M C
S		 V M
S		 C
W F
 

None

                  

IV. SUPPORTING INFORMATION AND POSSIBLE DESIGN CONSIDERATIONS

A. Other Instructions:

X-Ref Requirement Instructions
3929.3 Spanish version of MSn message 16.25 "Medicare no paga por tantos servicios o suministros"
3929.5 CR 3834, issued May 20, 2005, lists the Condtions for coverage of Smoking and Tobacco-Use Cessation Counseling.
3929.5 Chapter 30 of the Medicare Claims Processing Manual may be referenced for further information on financial liability

B. Design Considerations: N/A

X-Ref Requirement # Recommendation for Medicare System Requirements

C. Interfaces: N/A
D. Contractor Financial Reporting /Workload Impact: N/A
E. Dependencies: N/A
F. Testing Considerations: N/A

V. SCHEDULE, CONTACTS, AND FUNDING

Effective Date*: October 1, 2005
Implementation Date: October 3, 2005
Pre-Implementation Contact(s): William Larson (coverage), 410.786.4639,
William.Larson@cms.hhs.gov,
Thomas Dorsey, 410.0786.7434,
Thomas.Dorsey@cms.hhs.gov, (carrier billing)
Yvonne Young, 410.786.1886,
Yvonne.Young@cms.hhs.gov (FI billing)
Post-Implementation Contact(s): Regional office

No additional funding will be provided by CMS; contractor activities are to be carried out within their FY 2005 operating budgets.

*Unless otherwise specified, the effective date is the date of service

12.4 - Remittance Advice (RA) Notices
(Rev.605, Issued: 07-15-05, Effective: 10-01-05, Implementation: 10-03-05)
Contractors shall use the appropriate claim RA(s) when denying payment for smoking and tobacco-use cessation counseling services.

The following messages are used where applicable:

12.5 - Medicare Summary Notices (MSNs)
(Rev.605, Issued: 07-15-05, Effective: 10-01-05, Implementation: 10-03-05)
When denying claims for counseling services that were performed prior to the effective date of coverage, contractors shall use an appropriate MSN, such as, MSN 21.11, “This service was not covered by Medicare at the time you received it.” When denying claims for counseling services on the basis that the coverage criteria were not met, use an appropriate MSN, such as MSN 20.21, “This service was denied because Medicare only covers this service under certain circumstances.”

When denying claims for counseling services that have dates of service exceeding the maximum benefit allowed, use an appropriate MSN, such as MSN 16.25, “Medicare does not pay for this much equipment, or this many services or supplies.”

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Implementation of the Centers for Medicare & Medicaid Services (CMS) Ruling 05-01 Regarding Presbyopia-Correcting Intraocular Lenses (IOLs) for Medicare Beneficiaries

Provider Types Affected
Physicians, providers, and suppliers billing Medicare carriers or Fiscal Intermediaries (FIs) for IOLs

Provider Action Needed

STOP – Impact to You
In a recent ruling, the Centers for Medicare & Medicaid Services (CMS) clarified payment rules that enable Medicare beneficiaries to have the choice of receiving presbyopia-correcting intraocular lenses (IOLs). A beneficiary may request insertion of a presbyopia-correcting IOL in place of a conventional IOL following cataract surgery.

CAUTION – What You Need to Know
The beneficiary is responsible for payment of that portion of the charge for the presbyopia-correcting IOL and associated services that exceed the charge for insertion of a conventional IOL following cataract surgery.

GO – What You Need to Do
See the Background and Additional Information sections of this article for further details regarding this change.

Background
The Centers for Medicare & Medicaid Services (CMS) recently announced a ruling (CMS Ruling 05-01 dated May 2005) that clarified its payment rules to present beneficiaries with the choice to receive presbyopia-correcting intraocular lenses (IOLs). Prior to this ruling, limitations on Medicare payment prevented beneficiaries from receiving these lenses. Now beneficiaries who choose to purchase this additional feature will be able to do so, provided they assume liability for the additional expense of that feature.

Note: CMS Ruling 05-01 is included below in the Additional Information section of this Special Edition article.

Presbyopia-Correcting IOL
Presbyopia is a type of age-associated refractive error that results in progressive loss of the focusing power of the lens of the eye, causing difficulty seeing objects at near distance, or close-up. Presbyopia occurs as the natural lens of the eye becomes thicker and less flexible with age.

A single presbyopia-correcting IOL can provide what would otherwise be achieved by two separate items:

Note: The statute specifically excludes correction of common refractive errors from Medicare coverage.

Coverage Ruling
Payment for conventional IOLs furnished in an outpatient setting is covered by Medicare. However,
providers have generally not offered beneficiaries presbyopia-correcting IOLs because the costs for this advanced technology substantially exceed Medicare’s payment.

This ruling by CMS clarifies that a beneficiary may request insertion of a presbyopia-correcting IOL in place of a conventional IOL following cataract surgery.

The beneficiary is responsible for payment of that portion of the charge for the presbyopia-correcting IOL and associated services that exceed the charge for insertion of a conventional IOL following cataract surgery.

Effective for services furnished on or after May 3, 2005, the following are considered “presbyopia-correcting IOLs” by CMS:

As a result of CMS ruling 05-01, the following policies may be stated:

Payment Policy for Facility Services and Supplies

Payment Policy for Physician Services and Supplies

Coding Requirements

Beneficiary Liability

Provider Notification Requirements

Additional Information
The actual CMS ruling may be viewed at http://www.cms.hhs.gov/rulings/CMSR0501.pdf on the CMS Web site.

For complete details, please see the official instruction issued to your carrier or intermediary regarding this change, which may be found by going to http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site.
From that Web page, look for CR 3927 in the CR NUM column on the right, and click on the file for that CR.

If you have any questions, please contact your Medicare carrier or intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

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Posters Now Available!

Posters titled “Have Limited Income? Social Security Can Help with Prescription Costs” can be ordered free of charge on the Centers for Medicare and Medicaid Services’ (CMS) Web site. The posters are suitable for display in a physician’s, provider’s, or supplier’s office, a pharmacy, or other health care setting where Medicare beneficiaries will see this information. The posters direct Medicare beneficiaries with limited income to a toll free number where they can find out if they are eligible for help with prescription drug costs. Flat posters are suitable for wall display. Easel posters are suitable for counter display. Order the size and style appropriate for your use. Artwork cannot be specified as posters will be sent based on availability at the time the order is received. To view and order the posters, go to the Medlearn Prescription Drug Coverage Web page located at: http://www.cms.hhs.gov/medlearn/drugcoverage.asp on the CMS Web site. We need your help in getting this information out to Medicare beneficiaries with limited income and resources. We encourage you to order and display the posters where Medicare beneficiaries will see them.

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Requirements for Voided, Canceled, and Deleted Claims

Note: This article was revised on October 4, 2005, to correct errors on page 2. Specifically, references to form HCFA 1500 were corrected to state form CMS 1500.

Provider Types Affected
All Medicare physicians, providers, and suppliers billing Medicare carriers, Durable Medical Equipment Regional Carriers (DMERCs) and Fiscal Intermediaries (FIs)

Provider Action Needed
This Medlearn Matters article is based on information contained in Change Request (CR) 3627, which describes new CMS procedures and specific instructions to Medicare Contractors (Medicare carriers, intermediaries, and DMERCs) for voiding, canceling, and deleting claims.

As a result of these changes, providers should note that some claims they were able to delete in the past will no longer be deleted from Medicare’s systems, but will instead become denied claims.

Background
The Department of Health and Human Services (DHHS) Office of the Inspector General (OIG) has verified instances in which Medicare claims have been voided, cancelled, or deleted by Medicare carriers, DMERCs, and FIs. Further, the Medicare contractors have not traditionally maintained an audit trail for the voided, cancelled, or deleted claims. The OIG has indicated that Medicare must maintain an audit trail for voided, cancelled, and deleted claims.

The Centers for Medicare & Medicaid Services (CMS) is therefore implementing requirements for Medicare contractors (carriers/FIs, including DMERCs and Regional Home Health Intermediaries (RHHIs)) to:

Note: CR3627 requires that Medicare carriers, intermediaries, and DMERCs keep an audit trail on these claims once a CCN or DCN has been assigned to the claim.

Acceptable Claims Deletions
Below is a list of acceptable reasons a Medicare contractor may cancel, delete, or void a claim:

  1. The current CMS 1500 form or the current CMS 1450 form is not used.
  2. The front and back of the CMS 1500 (12/90) claim form are required on the same sheet and are not submitted that way (claims submitted to carriers only).
  3. A breakdown of charges is not provided, i.e., an itemized receipt is missing.
  4. Only six line items have been submitted on each CMS 1500 claim form (Part B only).
  5. The patient’s address is missing.
  6. An internal clerical error was made.
  7. The Certificate of Medical Necessity (CMN) was not with the claim (Part B only).
  8. The CMN form is incomplete or invalid (Part B only).
  9. The name of the store is not on the receipt that includes the price of the item (Part B only).

Note: The Medicare contractor must keep an audit trail for all claims in the above “Acceptable Claims Deletions” category if a CCN or a DCN was assigned to the claim.

Unacceptable Claims Deletions
The following are unacceptable reasons for Medicare contractors to void, cancel, or delete claims:

  1. A provider notifies the Medicare contractor that claim(s) were billed in error and requests the claim be deleted (carrier claims only).
  2. The provider goes into the claims processing system and deletes a claim via any mechanism other than submission of a cancel claim (Type of Bill xx8). Providers may only cancel claims that are not suspended for medical review or have not been subject to previous medical review. (FI claims only)
  3. The patient’s name does not match any Health Insurance Claim Number (HICN).
  4. A claim meets the criteria to be returned as unpro cessable under the incomplete or invalid claims instructions in the Medicare Claims Processing Manual, Chapter 1, Section 80.3.2.ff, which is available at http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp on the CMS Web site.

Medicare contractors must deny or reject claims in the above “Unacceptable Claims Deletions” category.

Return as Unprocessable Claims
Medicare contractors may return a claim as unprocessable for the following reasons:

  1. Valid procedure codes were not used and/or services are not described (e.g., block 24D of the CMS 1500) (Part B only).
  2. The patient’s HICN is missing, incomplete, or invalid (e.g., block 1A of the CMS 1500).
  3. The provider number is missing or incomplete.
  4. No services are identified on the claim.
  5. Block 11 (insured policy group or FECA Number) of the CMS 1500 is not completed to indicate whether an insurer primary to Medicare exists (Part B only).
  6. The beneficiary’s signature information is missing (Part B only).
  7. The ordering physician’s name and/or UPIN are missing/invalid (blocks 17 and 17A of the CMS 1500).
  8. The place of service code is missing or invalid (block 24B of the CMS 1500 – Part B only).
  9. A charge for each listed service is missing (e.g., block 24F of the CMS 1500).
  10. The days or units are missing (e.g., block 24G of the CMS 1500).
  11. The signature is missing from block 31 of the CMS 1500 (Part B only).
  12. Dates of service are missing or incomplete (block 24A of the CMS 1500).
  13. A valid HICN is on the claim, but the patient’s name does not match the name of the person assigned that HICN.

Summary
In summary, CMS believes the following:

If a Medicare contractor determines that a claim is unprocessable before the claim enters that contractor’s claims processing system (i.e., the claim processing system did not assign a CCN or DCN to the claim):

If a Medicare contractor determines that a claim is unprocessable after the claim enters their claims processing system (i.e., the claim processing system did assign a CCN or DCN to the claim):

The Medicare contractor must maintain an audit trail for all deleted claims that have entered the claims processing system (i.e., the system assigned a CCN or DCN to the claim).

Implementation
The implementation date for the instruction is October 3, 2005.

Additional Information
For complete details, please see the official instruction issued to your carrier/intermediary regarding this change. That instruction may be viewed by going to http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site. From that Web page, look for CR3627 in the CR NUM column on the right, and click on the file for that CR.

If you have any questions, please contact your carrier/intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

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Fiscal Year (FY) 2006 Payment for Services Furnished in Ambulatory Surgical Centers (ASCs)

Provider Types Affected
Ambulatory Surgical Centers (ASCs) billing Medicare carriers or intermediaries

Provider Action Needed
This instruction advises that the current ACS payment rates and wage index values remain in effect for FY 2006.

Background
Section 626(a) of the Medicare Modernization Act (MMA) mandates, for ASC payment rates, a zero percent increase for inflation in FY 2005, the last quarter of Calendar Year (CY) 2005, and each calendar year from CY 2006 through CY 2009.

Wage Index Values
The implementation of new wage index values for FY 2006 is deferred until the Centers for Medicare & Medicaid Services (CMS) has had an opportunity to determine the impact of changes in the FY 2006 inpatient hospital wage index on payment amounts for individual ASCs. Therefore, payments to ASCs for services furnished on or after October 1, 2005, will not change.


Until further notice, Medicare carriers will continue to use the FY 2004 wage index to calculate payments to ASCs and continue to use the payment rates that were effective for services furnished on or after April 1, 2004.

The labor-related portion of ASC payment rates is defined currently as 34.45 percent of the payment rate. Carriers are currently using the FY 2004 hospital inpatient wage index to calculate payments for ASC services.

Transmittal AB-03-116 (CR2871), issued August 8, 2003, updated ASC facility payment rates for inflation and updated the wage index values used to adjust ASC payments for geographic wage differences effective for services furnished on or after October 1, 2003. CR2871 may be found at http://www.cms.hhs.gov/manuals/pm_trans/AB03116.pdf on the CMS Web site.

Transmittal 51 (CR3082), issued February 4, 2004, notified contractors about a change in ASC payment rates effective April 1, 2004, resulting from enactment of Section 626(a) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). CR3082 may be found at http://www.cms.hhs.gov/manuals/pm_trans/R51OTN.pdf on the CMS Web site.

ASC Payment Group Rates
The ASC payment group rates will remain as follows:

Group 1 $333 Group 6 826 ($676 + 150 for intraocular lenses (IOLs)
Group 2 $446 Group 7 $995
Group 3 $510 Group 8 $973 (823+150 for IOLs)
Group 4 $630 Group 9 $1339
Group 5 $717    

Additional Information
The CMS Web site for ASC information can be found at http://www.cms.hhs.gov/suppliers/asc on the CMS Web site.

The official instruction issued to your carrier/intermediary regarding this change may be found at
http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site. From that
Web page, look for CR4075 in the CR NUM column on the right, and click on the file for that CR.

If you have questions regarding this issue, please contact your carrier/intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

Evaluation and Management Visits Online Training Course

Web-Based Training on “Evaluation and Management Basics and Common Errors” is now available on the CIGNA Government Services Web site. This NetCourse was developed by CIGNA Government Services Part B Medical Review staff based on the guidelines established by the Centers for Medicare and Medicaid Services. This NetCourse is the first of three netcourses on evaluation and management documentation guidelines and scoring. The second and third courses will be forthcoming. Providers should watch the CGS Web site or enroll in ListServe to receive announcement on release of these other courses. All of the courses are designed to educate and faciliate providers’ selection of the appropriate (i.e. medically necessary) level of E&M service to bill to Medicare. The courses reflect the guidelines used by the Medical Review department as well as the Comprehensive Error Rate Testing program on the review of E&M services. Providers are encouraged to have whoever determines in their practice the level of E&M encounters billed to Medicare to take this course. This course can be accessed via the following Web address: http://www.cignamedicare.com/Webtraining/Logon.asp

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October 2005 Quarterly Fee Schedule Update for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)

Provider Types Affected
Physicians, suppliers, and providers billing Medicare carriers, including Durable Medical Equipment Regional Carriers (DMERCs) and/or Fiscal Intermediaries (FIs), including Regional Home Health Intermediaries (RHHIs), for services paid under the DMEPOS Fee Schedule

Provider Action Needed
This article is based on Change Request (CR) 4026 and provides specific information regarding the October quarterly update of the 2005 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) fee schedule.

Background
The DMEPOS fee schedules are updated on a quarterly basis in order to:

Note: There are no changes to the PEN fee schedule file for October 2005.
The following codes are being added to the Healthcare Common Procedure Coding System (HCPCS) on October 1, 2005, and are effective for claims with dates of service on or after October 1, 2005:

Code Description of Code

Q0480 Driver for use with pneumatic ventricular assist device, replacement only
Q0481 Microprocessor control unit for use with electric ventricular assist device, replacement only
Q0482 Microprocessor control unit for use with electric/pneumatic combination ventricular
assist device, replacement only
Q0483 Monitor/display module for use with electric ventricular assist device, replacement only
Q0484 Monitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0485 Monitor control cable for use with electric ventricular assist device, replacement only
Q0486 Monitor control cable for use with electric/pneumatic ventricular assist device, replacement only
Q0487 Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist device, replacement only
Q0488 Power pack base for use with electric ventricular assist device, replacement only
Q0489 Power pack base for use with electric/pneumatic ventricular assist device, replacement only
Q0490 Emergency power source for use with electric ventricular assist device, replacement only
Q0491 Emergency power source for use with electric/pneumatic ventricular assist device, replacement only
Q0492 Emergency power supply cable for use with electric ventricular assist device, replacement only
Q0493 Emergency power supply cable for use with electric/pneumatic ventricular assist device, replacement only
Q0494 Emergency hand pump for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0495 Battery/power pack charger for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0496 Battery for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0497 Battery clips for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0498 Holster for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0499 Belt/vest for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0500* Filters for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0501 Shower covers for use with electric or electric/pneumatic ventricular assist device, replacement only
Q0502 Mobility cart for pneumatic ventricular assist device, replacement only
Q0503 Battery for pneumatic ventricular assist device, replacement only, each
Q0504 Power adapter for pneumatic ventricular assist device, replacement only, vehicle type
Q0505 Miscellaneous supply or accessory for use with ventricular assist device

* Replacement filters described by code Q0500 are furnished in boxes of varying quantities by different manufacturers. Therefore, the base unit for code Q0500 for billing purposes is per each filter.

Note: Instructions regarding the implementation of the above codes were furnished in CR3931.

The following table describes upcoming changes in certain HCPCS codes for wheelchairs beginning October 1, 2005.

HCPCS CODE New Information

E0971 (anti-tipping device for wheelchairs) The fee schedule amount for code E0971 is being revised to reflect a base billing unit of "EACH." Up to this point E0971 represented "each" or a "pair" of devices. In October the fee scheule will be standardized to represent fees per each unit.
E1038 & E1039 (transport chairs) The fee schedule amounts for E1038 are being revised to correct errors in the fee calculations and reflect changes in billing for items under these codes. The fees erroneously included elevating leg rests and those should be billed separately using code K0195. The updated schedule will no longer include prices for the leg rests.
K0195(elevating leg rests) Suppliers should be billing these leg rests under this code.
E1039
(transport chairs with patient
weight capacity over 300 pounds)		 Claims dated on/after October 1, 2005 should contain E1039 for chairs with weight capacity OVER 300 pounds.
E1038 (transport chairs with patient
weight capacity under 300 pounds)		 Claims dated on/after October 1, 2005 should contain E1038 for chairs with weight capacity of 300 pounds or less.
E1238 (Pediatric size, folding, adjustable wheelchair without seating system) The fee schedule is being revised for E1238 to correct fee schedule calculation errors.

HCPCS codes L3000 through L3649 were added to the fee schedule file effective July 1, 2005, for use in paying claims for shoes that are an integral part of an orthoses.

L5685 was added to the HCPCS effective January 1, 2005. The fee schedules are being established as part of this report.

Implementation
The implementation date for this instruction is October 3, 2005.

Additional Information
For complete details, please see the official instruction issued to your carrier/DMERC/intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS Web site. From that Web page, look for CR4026 in the CR NUM column on the right, and click on the file for that CR.

If you have any questions, please contact your carrier/DMERC/intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf on the CMS Web site.

Also, the quarterly updates process for the DMEPOS fee schedule is located in the Medicare Claims Processing Manual (Pub 100-04, Chapter 23, Section 60). This manual can be accessed at http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp on the CMS Web site.

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Manual Update on Medical Nutrition Therapy (MNT) Services - Manualization

NOTE: Transmittal 650, dated August 12, 2005, is rescinded and is replaced with Transmittal 673, dated, September 9, 2005 because a strike out was inadvertently left in §300.4 (Payment for MNT Services) of the manual portion of the instruction. All other information in the revision remains the same.

I. SUMMARY OF CHANGES: This instruction manualizes sections in the current Internet Only Manual (IOM) for Medical Nutrition Therapy Services (Pub 100-04, Sections 300 through 300.6). The definition for diabetes mellitus has been changed based on the 2003 Medicare Physician Fee Schedule Regulation. Also, material that was excluded from the new IOM has been added.

MANUALIZATION
EFFECTIVE DATE : NON-APPLICABLE
IMPLEMENTATION DATE : NON-APPLICABLE

Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.

II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)
R = REVISED, N = NEW, D = DELETED – Only One Per Row.

R/N/D Chapter/Section/Subsection/Title
R 4/Table of Contents
R 4/300/Medicare Nutrition Therapy (MNT) Services
N 4/300.1/General Conditions and Limitations on Coverage
N 4/300.2/Referrals for MNT Services
N 4/300.3/Dietitions and Nutritionists Performing MNT Services
N 4/300.4/Payment for MNT Services
N 4/300.5/General Claims Processing Information
N 4/300.6/Common Working File (CWF) Edits

III. FUNDING:
No additional funding will be provided by CMS; Contractor activities are to be carried out within their FY 2005 operating budgets.

IV. ATTACHMENTS:
Business Requirements
Manual Instruction
*Unless otherwise specified, the effective date is the date of service.

NOTE: Transmittal 650, dated August 12, 2005, is rescinded and is replaced with Transmittal 673, dated, September 9, 2005 because a strike out was inadvertently left in §300.4 (Payment for MNT Services) of the manual portion of the instruction. All other information in the revision remains the same.

I. GENERAL INFORMATION

A. Background: Effective January 1, 2004, the definition for diabetes mellitus was changed. This change is being incorporated into the internet only manual (IOM) for MNT services. Additional information that was not included in the IOM is also being added.

B. Policy: This change is per volume 68, #216, November 7, 2003, page 63261/Federal Register.
II. BUSINESS REQUIREMENTS
“Shall” denotes a mandatory requirement
“Should” denotes an optional requirement

Requirement Number Requirements Responsibility ("X" indicates the columns that apply)
    F I R H
H
I		 C a
r
r
i
e
r
s		 D M E
R
C		 Shared System Maintainers Other
 
F I
S
S		 M C
S		 V M
S		 C W
F
3955.1 Contractors and maintainers shall be in compliance with the manual instruction in Publication 100-04, Chapter 4, Section 300. X   X            

III. PROVIDER EDUCATION

Requirement Number Requirements Responsibility ("X" indicates the columns that apply)
    F I R
H
H
I		 C
a
r
r
i
e
r
s		 D M
E
R
C		 Shared System Maintainers Other
F
I
S
S		 M
C
S		 V
M S		 C
W
F
3955.2 Contractors shall post this entire instruction, or a direct link to this instruction, on their Web site and include information about it in a listserv message within 1 week of the release of this instruction. In addition, the entire instruction must be included in your next regularly scheduled bulletin and incorporated into any education events on this topic. X   X          


IV. SUPPORTING INFORMATION AND POSSIBLE DESIGN CONSIDERATIONS

A. Other Instructions: N\A

X-Ref Requirement # Instructions

B. Design Considerations: N\A

X-Ref Requirement # Recommendation for Medicare System Requirements

C. Interfaces: N/A

D. Contractor Financial Reporting /Workload Impact: N/A

E. Dependencies: N/A

F. Testing Considerations: N/A

V. SCHEDULE, CONTACTS, AND FUNDING

Effective Date*: N/A
Implementation Date: N/A
Pre-Implementation Contact(s): for Part A issues, Taneka Rivera at taneka.rivera@cms.hhs.gov or 410.786.9502 for Part B issues,
Yvette Cousar at yvette.cousar@cms.hhs.gov or 410.786.2160
Post-Implementation Contact(s): Appropriate Regional Office (RO)		 No additional funding will be provided by CMS; Contractor activities are to be carried out within their FY 2005 operating budgets.

*Unless otherwise specified, the effective date is the date of service.

Medicare Claims Processing Manual

Chapter 4 - Part B Hospital (Including Inpatient Hospital Part B and OPPS)

Table of Contents
(Rev.673, 09-09-05)

300- Medical Nutrition Therapy (MNT) Services

300.1 – General Conditions and Limitations on Coverage

300.2 – Referrals for MNT Services

300.3 – Dietitians and Nutritionists Performing MNT Services

300.4 – Payment for MNT Services

300.5 – General Claims Processing Information

300.6 – Common Working File (CWF) Edits

300 - Medical Nutrition Therapy (MNT) Services

(Rev.673, Issued: 09-09-05, Effective: N/A, Implementation: N/A)
Section 105 of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) permits Medicare coverage of Medical Nutrition Therapy (MNT) services when furnished by a registered dietitian or nutrition professional meeting certain requirements. The benefit is available for beneficiaries with diabetes or renal disease, when referral is made by a physician as defined in §1861(r)(l) of the Act. It also allows registered dietitians and nutrition professionals to receive direct Medicare reimbursement for the first time. The effective date of this provision is January 1, 2002. The benefit consists of an initial visit for an assessment; follow-up visits for interventions; and reassessments as necessary during the 12-month period beginning with the initial assessment (“episode of care”) to assure compliance with the dietary plan. Effective October 1, 2002, basic coverage of MNT for the first year a beneficiary receives MNT with either a diagnosis of renal disease or diabetes as defined at 42 CFR, 410.130 is 3 hours. Also effective October 1, 2002, basic coverage in subsequent years for renal disease is 2 hours.

For the purposes of this benefit, renal disease means chronic renal insufficiency or the medical condition of a beneficiary who has been discharged from the hospital after a successful renal transplant within the last 6 months. Chronic renal insufficiency means a reduction in renal function not severe enough to require dialysis or transplantation (glomerular filtration rate (GFR) 13-50 ml/min/1.73m²). Effective Janaury 1, 2004, CMS updated the definition of diabetes to be as follows: Diabetes is defined as diabetes mellitus, a condition of abnormal glucose metabolism diagnosed using the following criteria: a fasting blood sugar greater than or equal to 126 mg/dL on two different occasions; a 2 hour post-glucose challenge greater than or equal to 200 mg/dL on 2 different occasions; or a random glucose test over 200 mg/dL for a person with symptoms of uncontrolled diabetes.

The MNT benefit is a completely separate benefit from the diabetes self-management training (DSMT) benefit. CMS had originally planned to limit how much of both benefits a beneficiary might receive in the same time period. However, the national coverage decision, published May 1, 2002, allows a beneficiary to receive the full amount of both benefits in the same period. Therefore, a beneficiary can receive the full 10 hours of initial DSMT and the full 3 hours of MNT. However, providers are not allowed to bill for both DSMT and MNT on the same date of service for the same beneficiary.

300.1 General Conditions and Limitations on Coverage

(Rev.673, Issued: 09-09-05, Effective: N/A, Implementation: N/A)

A. General Conditions on Coverage

The following are the general conditions of coverage:

B – Limitations on Coverage
The following limitations apply:

300.2 Referrals for MNT Services

(Rev.673, Issued: 09-09-05, Effective: N/A, Implementation: N/A)

Medicare covers 3 hours of MNT in the beneficiary’ s initial calendar year. No initial hours can be carried over to the next calendar year. For example, if a physician gives a referral to a beneficiary for 3 hours of MNT but a beneficiary only uses 2 hours in November, the calendar year ends in December and if the third hour is not used, it cannot be carried over into the following year. The following year a beneficiary is eligible for 2 follow-up hours (with a physici